1. Human Factors and Signals Passed at Danger Dr Huw Gibson Dr Ann Mills RSSB

2. Rail Safety24 November 2015 Presentation Overview GB Rail and Signals Passed at Danger (SPADs) Summary of Investigation in to Human Factors and Signals Passed at Danger Proposed industry changes 2

3. Rail Safety24 November 2015 SPADS in context of total accidental system risk 3

4. Rail Safety24 November 2015 GB reporting, resources and research 4

5. Industry Human Factors SPAD Review

6. Rail Safety24 November 2015 Project Objectives Develop new and fuller insights in to the human factors issues associated with SPAD incidents Work with industry to identify the strengths and any potential weaknesses in SPAD management processes Help to assure that human factors associated with SPADs are effectively managed

7. Rail Safety24 November 2015 How do we manage SPADs better? 1.Identify the underlying causes of SPAD incidents –Reviewing SPAD investigation reports –Looking at how investigations could be improved 2.Communicating the underlying cause information to all staff and implementing improvements in SPAD management processes Workshops with industry: drivers, managers for railway undertakings, signallers, managers for the infrastructure manager (Network Rail) Challenging individual companies to do steps one and two 7

8. How to communicate underlying causes

9. Rail Safety24 November 2015 9 Equipment Environment Knowledge, skills and experience Communication

10. Rail Safety24 November 201510 Information Practices and Processes Personal Factors Supervision and Management Workload Teamwork

11. Rail Safety24 November 2015 Ten Incident Factors – Alstom Prompt Card 11 The 10 incident factors

12. What are the underlying causes?

13. Rail Safety24 November 2015 SPAD Data Collected 257 SPAD Incident Investigation Reports Reviewed 924 Causal/Contributory Factors, average four per incident 197 Passenger, 54 Freight, 184 Network Rail By Year: 13 2011201220132014 70621169

14. Rail Safety24 November 2015 SPAD 10 Incident Factor causes 14

15. Conclusions

16. Rail Safety24 November 2015 Key Challenge to Industry 16

17. Rail Safety24 November 2015 Conclusions Identifying underlying causes profiles is the first step in understanding the human factors associated with SPADs Need to focus on the safety management system, not the train driver By involving drivers, managers and company directors in reviewing underlying causes and identifying improvements we can: Fix recurrent issues across SPAD incidents Support the development of a Just Culture around SPADs 17

18. Thank you